-------[ RESEARCH REPORT ] -------

PHILIP MALLOY, PT, PhD 1 2 • DONALD A. NEUMANN, PT, PhD3 • KRISTOF KIPP, PhD 34

Hip Biomechanics During a Single-Leg

Squat: 5 Key Differences Between People
With Femoroacetabular Impingement
Syndrome and Those Without Hip Pain
to assess for symptomatic im­

H
ip biomechanics during tasks such as walking,
pingement in people with FAI
squatting, and stair climbing are altered in people
syndrome. 5,11,33
with femoroacetabular impingement (FAI) The kinematic differences dur­
syndrome .2,9,10,15’19’24" 26’35’36 However, most of these ing a double-leg squat in people
studies have investigated gait,12,19,21,24,35,36 which is a task that with FAI syndrome compared to
does not require hip positions expected to reproduce symptomatic those without hip pain include reduced
impingement in people with FAI syndrome. Gait does not require sagittal plane pelvic range of motion , 25
reduced peak hip internal rotation , 2
near-end ranges of hip flexion, internal rotation, and adduction
and greater anterior pelvic tilt at peak
motions .12,19,21’24,35 Therefore, squat tasks might be more appropriate — hip flexion. 2 Some people with FAI syn­
hoc analyses for all variables with a significant drome may have altered hip joint inter­
• BACKGROUND: The hip joint biomechanics
of people with femoroacetabular impingement group-by-task interaction were performed to iden­ nal moments, such as smaller average
(FAI) syndrome are different from those of healthy tify between-group differences for each task. hip extension2 and peak internal rota­
people during a double-leg squat. However, • RESULTS: There were significant group-by­ tion moments, 10’24 compared to healthy
information on biomechanics during a single-leg task interactions for peak hip joint (P = .014, q2 = controls. Although a double-leg squat is
squat is limited. 0.211) and thigh segment (P = .009, q2 = 0.233) useful in bringing out pelvic and hip mo­
• OBJECTIVES: To compare hip joint biomechan­ adduction angles, and for peak hip joint abduction
tion compensations in patients with FAI
(P = .002, q2 = 0.308) and extension (P = .016,
ics between people with FAI syndrome and people syndrome, the bilateral nature of this task
q2 = 0.203) internal moments. There were no
without hip pain during double-leg and single-leg
significant group-by-task interactions for squat may make it less challenging for a young
squats.
performance variables. or active patient. A single-leg squat task
• METHODS: Fourteen people with FAI syndrome is inherently more challenging and could
8 CONCLUSION: Biomechanical differences at
(cam, n = 7; pincer, n = 1; mixed, n = 6) and
the hip between people with FAI syndrome and accentuate movement compensations.
14 people without hip pain participated in this
those without hip pain were exaggerated during a People with FAI syndrome have kine­
cross-sectional, case-control, laboratory-based
single-leg squat compared to a double-leg squat
study. Three-dimensional biomechanics data matic and kinetic alterations during a
task.
were collected while all participants performed a unilateral step-up task and a step-down
double-leg and a single-leg squat. Two-way mixed- • LEVEL OF EVIDENCE: Diagnosis, level 4. task, including slower stair ascent, great­
J Orthop Sports Phys Ther 2019;49(12):908-916.
model analyses of variance were used to assess er peak trunk flexion angles, greater peak
Epub 23 Jul 201 9. doi:10.2519/jospt.2019.8356
group-by-task interactions for hip joint angles, hip external rotation joint moments , 15
thigh and pelvis segment angles, hip joint internal r®. KEY WORDS: double-leg squat, hip biomechanics,
and greater hip flexion and anterior pel­
moments, and squat performance variables. Post hip joint, single-leg squat
vic tilt . 27

‘Department of Physical Therapy, Arcadia University, Glenside, PA. departm ent of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL. departm ent of Physical
Therapy, Marquette University, Milwaukee, Wl. ‘ Program in Exercise Science, Marquette University, Milwaukee, Wl. The study protocol was approved by the Institutional Review
Board at Marquette University. This study was funded through partial support from the Foundation for Physical Therapy Research's Promotion of Doctoral Studies II scholarship
award and from the Clinical and Translational Science Institute of Southeast Wisconsin (8UL1TR000055). The authors certify that they have no affiliations with or financial
involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr Philip Malloy,
Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 204-A, Chicago, IL 60612. E-mail: Philip_Malloy@rush.edu ® Copyright
©2019 Journal of Orthopaedic & Sports Physical Therapy51

908 I DECEMBER 2 0 1 9 | VOLUME 4 9 | NUMBER 12 | JOURNAL OF ORTHOPAEDIC CPSPORTS PHYSICAL THERAPY

 Understanding how people with FAI
syndrome perform different squat tasks
could help the clinician evaluate move­
ment patterns in FAI syndrome. The
purpose of this study was to determine
differences in hip joint biomechanics
between people with FAI syndrome and
people without hip pain during double­
leg and single-leg squat tasks. We hy­
pothesized that hip joint biomechanics
between people with FAI syndrome
and people without hip pain would be
different, and that the biomechanical
differences would be greater during a
single-leg squat task than during a dou­
ble-leg squat task.
METHODS
W
E USED A CROSS-SECTIONAL, CASE-
control design with 2 independent
variables. The first independent
variable was group, with 2 levels: people
with FAI syndrome and people without
hip pain. The second independent variable
was task, with 2 levels: double-leg squat
and single-leg squat.
Participants
Previous studies have reported effect
sizes on the order of 0.3 for biomechani­
cal differences between people with FAI
syndrome and people without hip pain
during various functional tasks.2'22 Thus,
to have a 90% chance of detecting an ef­
fect that accounted for 30% of the vari­
ance between the groups for the squat
tasks at an a priori alpha level of .05,13
D e m o g r a p h ic In f o r m a t io n f o r P e o p l e W it h
TABLE 1
1 FAI S y n d r o m e
FAI Syndrome (n = 14)
Sex, n
Male
Female
Age.y
Height, m
Weight, kg 76.3 ±18.2
Abbreviation: FAI.femoroacetabular impingement.
*Values are mean ± SD unless otherwise indicated.
JO U R N A L OF O R TH O PA E D IC & SPO RTS PHYSICAL TH ERA PY | VO LU M E 4 9
participants per group were needed for a
mixed-model statistical design.20 We en­
rolled 14 people with FAI syndrome and
14 people without hip pain in this study
(TABLE 1). All participants were between
14 and 40 years of age (mean + SD age,
24.4 ± 6.4 years) at the time of the study
and signed a written informed-consent or
assent form prior to participation in this
study. The informed-consent/assent form
and study protocol were approved and in
compliance with all human subject pro­
tections set forth by the Institutional Re­
view Board of Marquette University.
All participants with FAI syndrome
were diagnosed by an orthopaedic sur­
geon specializing in young adult hip
preservation. Diagnosis of FAI syn­
drome required the following criteria:
(1) hip pain for at least 3 months; (2) a
positive anterior impingement (flexion,
adduction, internal rotation [FADIR])
test; (3) radiographic evidence of FAI,
defined by an alpha angle greater than
55° (cam morphology), center-edge
angle greater than 40° (pincer mor­
phology), or confirmed crossover sign
(pincer morphology); (4) a Tonnis grade
of 1 or less on a standard radiograph;
(5) magnetic resonance imaging with
no evidence of diffuse articular cartilage
degeneration; and (6) positive response
to an intra-articular anesthetic injec­
tion, which was defined as temporary
pain relief during impingement testing
immediately following the injection. We
excluded participants if they (l) reported
low back or lower extremity injury with­
a n d P e o p l e W i t h o u t H ip Pa i n *
No Hip Pain (n = 14) P Value
7 7
7 7
28 ± 7
21 ± 1 <.001
1.7 ±1.1
1.7 ±1.2 .87
71.3 ±15.5 .44
in the last 6 months, (2) had a history
of hip fracture or dislocation, (3) had a
previous diagnosis of any developmental
hip conditions such as acetabular dys­
plasia, or (4) had any systemic disorders
that limited activities of daily living.
We recruited a convenience sample of
people without hip pain from a general
university population to serve as a con­
trol group. We matched the groups for
sex, body mass, and height. Diagnosis of
FAI syndrome had to include “a triad of
symptoms, clinical signs, and imaging-
findings.”14 A licensed physical therapist
screened all controls using passive range
of hip motion and a physical examina­
tion (anterior impingement [FADIR]
test; flexion, abduction, external rota­
tion [FABER] test; log-roll test; and dial
test4-5-33) to determine whether symptoms
and clinical signs were present. Limited
hip flexion was less than 85°, and limited
internal rotation at 90° of hip flexion was
less than 10°. We excluded participants
if any examination technique elicited
anterior groin or lateral hip pain or met
the predetermined cutoffs for range-of-
motion limitation. One person without
hip pain failed the screening examination
secondary to pain during the FADIR test
and the flexion, abduction, external rota­
tion test.
Data Acquisition
We used a 14-camera motion-analysis
system (Vicon; Oxford Metrics, Yarn-
ton, UK) to sample position data at 100
Hz. Position data were recorded from
45 retroreflective markers, including
markers attached to individual anatomi­
cal landmarks (23 markers total) and 3
sets of rigid marker clusters attached to
the bilateral thigh, shank, and foot seg­
ments (22 markers total). Each thigh
and shank cluster contained 4 markers
and each heel cluster contained 3 mark­
ers. Individual markers were attached to
the following anatomical landmarks: C7
spinous process, T10 spinous process,
sternal notch, bilateral posterior superior
iliac spines, bilateral iliac crests, bilateral
anterior superior iliac spines, bilateral
| NUM BER 12 | D E C EM B E R 2 0 1 9 | 909

greater trochanters, bilateral medial and
lateral knee joint lines, bilateral medial
and lateral malleoli, bilateral fifth meta­
tarsal heads, and bilateral first metatarsal
heads. All markers were attached by the
same investigator for all participants.
A static standing trial was performed
with all markers to define segment pa­
rameters and estimate joint center loca­
tions. Participants stood in a self-selected
pelvic posture, with the feet positioned
at shoulder-width distance, the toes
pointed forward, and the arms raised to
approximately 90° of shoulder abduc­
tion, with the elbows in full extension.
Three-dimensional ground reaction force
data were sampled at 1000 Hz with 2 in-
ground force plates (Advanced Mechani­
cal Technology, Inc, Watertown, MA).
910 I D E C EM B E R 2 0 1 9 | V O LU M E 4 9
[ RESEARCH REPORT ]
Double-Leg and Single-Leg Squat Tasks
All squats were performed at self-se­
lected speeds to be more representative
of movement evaluations in the clinical
setting. We instructed participants to
“squat as low as possible while keeping
your feet/foot firmly in contact with the
force plate(s) at all times.” We did not use
a depth target; instead, we emphasized
a self-selected movement strategy to ac­
count for individual differences in hip
range of motion. Prior to data collection,
a task familiarization session was pro­
vided, which included an example squat
demonstration by the study staff. Partici­
pants completed 3 practice trials of each
squat task prior to data collection.
For the double-leg squat task, par­
ticipants stood with each foot on a force
| NU M BER 1 2 j JO U R N A L OF O R TH O PA E D IC
plate at shoulder-width distance and the
toes pointing forward (F IG U R E 1 ). For the
single-leg squat task, participants stood
on a force plate with the stance-limb
toes pointing forward and with the non-
stance limb held so that the knee was
flexed to a comfortable position, with
the nonstance thigh behind the squat
leg during the movement (FIG U R E 2 ) . Dur­
ing both squat tasks, participants raised
their arms to shoulder height, with their
fingertips pointing forward and palms
facing the floor.
Participants performed 5 successful
double-leg and single-leg squats to maxi­
mal depth. A successful trial was a squat
where the participant’s feet/foot remained
in contact with the force plate(s) through­
out the movement, stable balance was
& SPO RTS PH YSICA L TH ERA PY
maintained without shifting the stance analyzed both peak abduction and ad­ sures of self-reported physical function
foot/feet on the plate(s), and the non- duction angles and moments to account and quality of life in young people with
stance foot (single-leg squat) did not touch
for the different frontal plane kinematics nonarthritic hip pain.29,30
the ground. There was a 30-second break and kinetics that occur during each type
between each squat, and no more than 6 of squat task. Statistical Analysis
trials were collected per leg. We used the biomechanical model’s We inspected box plots for all dependent
virtual center of mass (CM)—calculated variables to evaluate the presence of out­
Data Processing and Analysis from the estimated masses of all seg­ liers. We used the Shapiro-Wilk test of
Kinematic and kinetic data were pro­ ments included in the model (the bilat­ normality to ensure all data were nor­
cessed with Visual3D software (C- eral thighs, shanks, and feet, as well as mally distributed, Levene’s test to ensure
Motion, Inc, Germantown, MD). Data the pelvis and trunk)—to determine the homogeneity of variance, and Box’s test to
were filtered with a fourth-order, low- squat cycle length and to calculate the evaluate the equality of covariance matri­
pass Butterworth filter at a cutoff fre­ squat performance variables. The start ces, as necessary, for repeated-measures
quency of 6 Hz. A hybrid link segment and end points of the squat cycle were analysis.
model was built using the CODA pelvis defined as when the CM vertical position We used 2-tailed independent-sam­
(Charnwood Dynamics Ltd, Rothley, was 3 SD away from the quiet stance CM ples t tests to assess between-group dif­
UK). Hip joint angles were defined as vertical position. Squat depth was the ferences in age, body mass, and height.
the angle between the thigh and pelvis change in CM position from quiet stance For group-by-task interactions, we used
segments, using an x-y-z (mediolateral, to the minimum vertical position during 2-way mixed-model analyses of variance
anteroposterior, longitudinal) Cardan the squat cycle. for all dependent variables. For any vari­
sequence of rotations, which are equiva­ We evaluated (1) descent phase, from able with a significant group-by-task in­
lent to flexion/extension, abduction/ad- the beginning of the squat cycle to the teraction, follow-up post hoc analyses,
duction, and internal/external rotation.7 minimum vertical CM position, and (2) consisting of a 2-tailed independent-
All pelvis and thigh segment angles are ascent phase, from the minimum verti­ samples t test, were performed to evalu­
reported with respect to the laboratory cal CM position to the end of the squat ate between-group differences for each
coordinate system. We used an inverse cycle. The first-time derivative of CM level of task. For dependent variables
dynamics approach to calculate net joint position was calculated to determine without a significant group-by-task in­
moments. All joint moments are report­ CM velocity. The average CM veloc­ teraction, main effects for group were re­
ed as internal moments and were nor­ ity was calculated for each phase of the ported using Bonferroni corrections for
malized to body mass (Newton meters squat cycle during each trial. We calcu­ multiple comparisons.
per kilogram). lated the 5-trial average for each squat The dependent biomechanical vari­
We extracted peak biomechanical performance variable. ables of interest were peak hip joint
variables from the non-time-normal­ Five people without hip pain per­ kinematics, peak thigh segment kine­
ized kinematic and kinetic waveforms formed 2 motion-analysis testing ses­ matics, peak pelvis segment kinematics,
prior to normalizing the data to 100 data sions, 7 days apart. We used these data to peak hip joint kinetics, and squat per­
points. We calculated 5-trial averages assess test-retest reliability for peak kine­ formance variables (TABLE 2 ). Effect sizes
for each peak biomechanical variable. matic and kinetic variables, using intra­ for the 2-way mixed-model analyses of
Because cam and/or pincer morphology class correlation coefficient (ICC) models. variance were evaluated with the partial
is often bilateral, we analyzed data from The average ICC33 for peak hip joint ki­ eta-square statistic and were interpreted
the involved hip of the FAI syndrome nematics was 0.75, with a standard error as small (approximately 0.01), medium
group and the matched leg of the con­ of measurement of 2.15°, and the average (approximately 0.06), and large (ap­
trol group.1,23 ICC33for hip joint kinetics was 0.78, with proximately 0.14).34 Cohen’s d was used
During a double-leg squat, the hip a standard error of measurement of 0.08 to estimate effect sizes for all univari­
joint moves into the direction of abduc­ Nm/kg. ate post hoc analyses and was defined
tion,2'24whereas during a single-leg squat as small (approximately 0.2), medium
the hip moves toward the direction of Patient-Reported Outcomes (approximately 0.5), and large (approxi­
adduction.1,3 Similarly, during a double­ Participants in the FAI syndrome group mately 0.8), as suggested by Cohen.6 An
leg squat, the predominant peak frontal completed the Hip Outcome Score ac­ a priori alpha level of .05 was used as
plane moment is in the direction of ad­ tivities of daily living subscale and In­ the threshold for statistical significance.
duction,224 whereas during a single-leg ternational Hip Outcome Tool-33 to All statistical testing was performed us­
squat this peak moment is in the oppo­ assess hip function and quality of life. ing SPSS Version 22 (IBM Corporation,
site direction (abduction). Therefore, we Both tools are reliable and valid mea­ Armonk, NY).

JO U R N A L O F O R TH O PA E D IC Elf SPO RTS PH YSICA L TH ERA PY | VO LU M E 4 9 | N U M B E R 1 2 | D E C EM B E R 2 0 1 9 | 911

 { RESEARCH REPORT ]
RESULTS FAI syndrome had moderate functional double-leg squat task, peak hip joint ad­
limitations (T A B L E 3 ) . 32 duction angles were similar between the
here were no d ifferen ces in FAI syndrome group and people without

T height or body weight (T A B L E 1 ) . Peo­

ple without hip pain were younger
than those with FAI syndrome (T A B L E 1 ) .
Seven people with FAI syndrome had
Hip Kinematics
There was a significant group-by-task
interaction for peak hip joint adduction
angle (F126 = 6.958, P = .014, q2 = 0.211)
hip pain (P = .68, d = 0.16) (F IG U R E 3 ) .
There was a significant group-by-task
interaction for peak thigh segment ad­
duction angle (F126 = 7-878, P = .009, q 2
cam morphology, 1 person had pincer (T A B L E 4 ) . During the single-leg squat task, = 0.233) (T A B L E 4 ) . People with FAI syn­
morphology, and 6 people had mixed people with FAI syndrome had 6° less drome had 4° less peak thigh segment ad­
morphology (ie, combined cam and pin­ peak hip joint adduction than people with­ duction during the single-leg squat task
cer morphology) (T A B L E 3 ) . People with out hip pain (P = .03, d = 0.87). During the when compared to people without hip
pain (P = .02, d = 0.92) (F IG U R E 4 ) . There
were no significant differences between
S tu d y D e s i g n , I n c l u d i n g t h e I n d e p e n d e n t
the FAI syndrome group and people
Va r ia b l e s (G r o u p a n d Ta s k ) and A ll
TABLE 2 without hip pain for peak thigh segment
D e p e n d e n t K i n e m a t i c , K i n e t i c , a n d S quat
adduction during the double-leg squat
P e r f o r m a n c e Va r ia b l e s o f I n t e r e s t *
task (P = .11, d = 0.63) ( F IG U R E 4 ) .
There was a significant main effect of
V a riab le M e a s u re m e n t
group for peak thigh segment abduction
Kinematic, deg • Peak hip joint flexion
angle (P = .017, q 2 = 0.200). There were
• Peak hip joint adduction
• Peak hip joint abduction
no other main effects of group (T A B L E 4 ) .
• Peak hip joint internal rotation
• Peak thigh segm ent flexion Hip Kinetics
• Peak thigh segm ent adduction There was a significant group-by-task in­
• Peak thigh segm ent abduction teraction for peak hip joint abduction in­
• Peak anterior pelvic tilt
ternal moment (F, 26 = 11.591, P = .002, q2
• Peak lateral pelvic tilU
= 0.308) (T A B L E 5 ) . On average, peak hip
Kinetic, N m /kg • Peak hip extension m om ent
joint abduction internal moments in peo­
• Peak hip abduction m om ent
• Peak hip adduction m om ent
ple with FAI syndrome were 30% of body
• Peak hip external rotation m om ent mass smaller than in people without hip
Squat performance • Center-of-mass depth, m pain during the single-leg squat task (P =
• Center-of-mass descent velocity, m/b .01, d = 1.04). There were no differences
• Center-of-mass ascent velocity, m/b in peak hip abduction internal moments
• Squat cycle duration, s during the double-leg squat task (P = .08,
*There were 2 tasks, the double-leg squat and single-leg squat, and 2 groups, those without hip pain d = 0.71) ( F IG U R E S ) .
and those with femoroacetabular impingement syndrome.
1Refers to contralateral pelvic drop.

Pa t i e n t -R e p o r t e d O u t c o m e S co r es an d
TABLE 3 | | Ra d io g r a p h i c M e a s u r e m e n t s f o r P e o p l e W it h
F e m o r o a c e t a b u l a r I m p i n g e m e n t Sy n d r o m e *

M e a s u re V alue

HOS-ADL, % 70.4 ± 1 3 .8
Task
iHOT-33, m m 45.0 + 17.5
Alpha angle, deg 63.5 + 8.8 F IG U R E 3 . Peak hip jo in t a dd u ctio n angles d uring

Lateral center-edge angle, deg 39.0 + 6.5 the d ou b le-le g and single-leg squat tasks in people
w ith fe m o ro a ce ta b u la r im p in g e m e n t syn dro m e (blue)
Crossover sign (positive case), n 3
and people w ith o u t hip pain (orange). Positive values
Abbreviations: HOS-ADL, Hip Outcome Score activities o f daily living subscale; iHOT-33, Interna­ represent add u ctio n and negative values represent
tional Hip Outcome Tool-33.
a b d u ctio n. "S ig n ific a n t (P < .0 5 ) post hoc difference of
*Values are mean ± SD unless otherwise indicated.
group fo r th e single-leg sq ua t task.

912 | D E C EM B E R 2019 | V O LU M E 49 | NUM BER 12 | JO U R N A L O F O R TH O PA E D IC & SPO RTS PH YSICA L TH ERA PY

 T here was a significant group-by-task
in teraction for peak hip jo in t extension
internal m om ents (F, 26 = 6.240, P = .016,
q2 = 0.203). On average, peak hip exten­
sion in ternal m om ents in people Math
FAI syndrom e were sm aller by 70% of
body m ass during th e single-leg squat
task (.P = .004, d = 1.27) and by 20% of
body m ass during th e double-leg squat
task (.P = .03, d = 1.00) when com pared to
people w ithout hip pain (FIGURE 6 ). There
were no other group-by-task interactions
or m ain effects of group (TABLE 5 ).
Squat Performance
There were no group-by-task interactions
for squat depth, squat cycle duration, and
squat descent and ascent velocity (TABLE 6 ).
People w ith FAI syndrome had a longer
squat cycle duration (P = .031, r f = 0.167),
slower squat descent velocity (P = .008, q1
= 0.244), and slower squat ascent velocity
(.P = .009, q2 = 0.237) than people w ith­
out hip pain. There was no m ain effect of
group for squat depth (P = .24, q 2 = 0.054)
(TABLE 6 ).
DISCUSSION
SINGLE-LEG SQUAT TASK EXAGGER-
A ated m ovem ent-pattern differences
betw een people w ith FAI syndrom e
an d those w ithout hip pain w hen com ­
pared to a double-leg squat task. D uring
a single-leg squat task, people w ith FAI
Double-leg Single-leg
squat squat
Task
FIGURE 4. Peak thigh segment adduction angles
during the double-leg and single-leg squat tasks in
people with femoroacetabular impingement syndrome
(blue) and people without hip pain (orange). Positive
values represent adduction and negative values
represent abduction. 'Significant (P<.05) post hoc
difference of group for the single-leg squat task.
JO U R N A L OF O R TH O PA E D IC
syndrom e squatted m ore slowly and w ith
less peak hip adduction th an people w ith­
out hip pain. People w ith FAI syndrom e
had lower peak hip jo in t abduction and
extension m om ents th an people w ithout
hip pain during a single-leg squat task.
The clinician m ight observe th a t patients
w ith FAI syndrom e perform a single-leg
squat slowly to avoid m edial collapse of
the thigh into hip adduction as th e hip
approaches near-end-range flexion. This
m ovem ent strategy may be developed to
avoid sym ptom atic bony im pingem ent
and to lim it jo in t load dem ands d u r­
ing single-leg squat tasks. T he clinician
m ight consider routinely assessing sin­
gle-leg squat perform ance in people w ith
FAI syndrome.
Five Key Biomechanical Differences
in Single-Leg Squat Performance
Between People With FAI Syndrome
and Those Without Hip Pain
In this section, we outline 5 m ain biom e­
chanical differences in single-leg squat
perform ance in p articip an ts w ith FAI
syndrome. One should consider th e kine­
m atic findings in the context of the sym p­
tom atic im pingem ent position in people
w ith FAI syndrome, w hich involves com ­
bined hip flexion, adduction, and internal
rotation. A lthough clinicians can only as­
sess m ovem ent patterns and not directly
observe internal jo in t m om ents, one may
consider how the observed hip m ovement
E
1 - 2.0 -
o
.9- -2.5 -
x ---- --------------------- ----
- 3 .0 -1----------- t------------------------------------ ,-----------
Double-leg
squat
Task
FIGURE 5. Peak hip abduction internal joint moments
during the double-leg and single-leg squat tasks
in people with femoroacetabular impingement
syndrome (blue) and people without hip pain
(orange). 'Significant (P<.05) post hoc difference of
group for the single-leg squat task.
0 SPO RTS PH YSICA L TH ERA PY | VO LU M E 4 9
patterns may affect th e hip internal jo in t
m om ents.
Smaller Peak Hip Joint and Thigh Seg­
m ent A dduction A ngles A lth o u g h
greater hip adduction m otion during a
single-leg squat is p a rt of an abnorm al
m ovem ent p attern in people w ith chronic
hip pain,16'17perhaps people w ith hip pain
specific to FAI syndrom e adopt a differ­
en t m ovem ent strategy. People w ith FAI
syndrom e did n ot collapse medially into
hip adduction during the single-leg squat.
The FAI syndrome group had 9° less peak
hip flexion during a single-leg squat but
only 2° less peak hip flexion during the
double-leg sq u at w hen com pared to
people w ithout hip pain. T he com bina­
tion of hip flexion and adduction m otion
during a single-leg squat could reproduce
sym ptom atic bony im pingem ent in peo­
ple w ith FAI syndrom e. These reduced
jo in t angles in people w ith FAI syndrom e
suggest a m ovem ent strategy to avoid re­
producing hip pain secondary to bony
im pingem ent th a t may occur w ith com ­
bined flexion and adduction.5,31
Smaller Peak Hip Abduction Joint Mo­
ments Internal jo in t m om ents mostly
reflect w hich muscle groups are active
during a task. Dynamic tasks th a t require
single-limb support often result in large
hip jo in t contact forces, with the hip m us­
cles being the prim ary contributor to these
forces.3'8,18,37Therefore, during a single-leg
squat, a large peak hip abduction internal
1 1
Double-leg Single-leg
Single-leg squat squat
squat Task
FIGURE 6. Peak hip extension internal joint moments
during the double-leg and single-leg squat tasks
in people with femoroacetabular impingement
syndrome (blue) and people without hip pain (orange).
'Significant (P<.05) post hoc difference of group for
the single-leg squat task. tSignificant (P<.05) post hoc
difference of group for the double-leg squat task.
| NU M BER 12 | D E C EM B E R 2 0 1 9 | 913
 [ RESEARCH REPORT }

moment would represent considerable
activity from the hip abductor muscle
group.37 In this context, the smaller peak
hip abduction moments in people with
FAI syndrome may signify a movement
strategy to limit hip abductor muscle ac­
tivity and, potentially, high joint contact
forces during this dynamic single-leg task.
Smaller Peak Hip Extension Joint Mo­
ments The between-group differences
for peak hip extension moments were
most pronounced during the single-leg
squat. Our double-leg squat extension
moment findings are consistent with
Bagwell and colleagues,- who found that
people with FAI syndrome demonstrate
smaller average hip extension moments
during a double-leg squat compared to
healthy controls. Because both types of
squats would require hip extensor muscle
activity, with greater activation required
during a single-leg squat, these findings
may also represent a movement strategy
to limit hip extensor muscle activity and,
potentially, high joint contact forces.
Slower CM Velocity During Squat­
ting Slower CM velocities during the
squat cycle might explain the lower peak
hip joint abduction and extension internal
moments in people with FAI syndrome,
and reflect a global squat performance
adaptation. This may be a strategy to
reduce the load demands across the hip
during squat tasks. Both types of squat
tasks require eccentric muscle activation
to halt momentum of the CM prior to the
ascent phase. During a double-leg squat,
the hip adductor muscles act eccentrically
to control hip joint abduction as the CM
descends (APPENDIX FIGURE 1, available at
www.jospt.org). Similarly, during a sin­
gle-leg squat, the hip abductor muscles

P eak Kinematic D ata D uring the D ouble -L eg and S ingle-L eg S quat

Tasks in P eople W ith FAI Syndrome and People W ithout H ip Pain

FAI Syndrome* No Hip Pain* P Value

DLS SLS DLS SLS Group Group by Task

Hip joint angles
Peak flexion 104.0 ±5.8 85.7 ±10.2 106.1 ±11.8 94.7 ±13.1 .14 .05
Peak adduction -4.3 ±2.5 10.2 ±4.3 -4.7 ±2.5 15.8 ±8.0 .01*
Peak abduction -13.9 ±5.1 1.0 ±2.6 -16.5 ±6.8 3.2 ±5.6 .86 .14
Peak internal rotation 9.2 ±8.4 4.6 ±8.2 12.7 ±7.5 7.0 ±6.2 .17 .79
Segment angles
Peak thigh flexion 80.4 + 11.0 43.6 ±8.5 85.3 ±20.8 55.4 ±12.8 .09 .14
Peak anterior pelvic tilt 33.4 ±6.1 40.4 ±8.3 33.4 ±7.8 39.0 ±7.9 .78 .65
Peak thigh adduction 0.9 ±8.6 10.3 ±3.3 -5.1 ±3.5 14.1 ±4.9 .01*
Peak thigh abduction -9.2 ±9.8 4.9 ±2.7 -14.4 ±6.0 4.4 ±2.8 .02* .06
Peak lateral pelvic tilt -2.8 ±1.6 -7.9 ±4.6 -2.9 ±3.5 -10.7 ±2.5 .15 .07
Abbreviations: DLS, double-leg squat; FAI.femoroacetabular impingement; SLS, single-leg squat.
* Values are mean ± SD degrees. Positive angles representflexion, adduction, internal rotation, and anterior pelvic tilt. Negative angles represent extension,

abduction, external rotation, and contralateral pelvic drop.

'Statistically significant interaction o f group by task.
•Main effect o f group.

Peak Kinetic Data D uring the D ouble -L eg and S ingle-L eg S quat Tasks
in People W ith FAI Syndrome and People W ithout H ip Pain

FAI Syndrome* jaM S No Hip Pain* P Value

DLS SLS DLS SLS Group Group by Task

Internal hip joint moments
Peak extension -1.0 ±0.2 -1.3 ±0.6 -1.2 ±0.2 -2.0 ±0.5 .02*
Peak adduction 0.4 ±0.2 -0.5 ±0.2 0.6 ±0.2 -0.5 ±0.1 .21 .06
Peak abduction -0.1 ±0.1 -0.8 ±0.3 -0.1 ±0.1 -1.1 ±0.3 <.01*
Peak external rotation -0.2 ±0.1 -0.1 ±0.2 -0.1 ±0.1 -0.5 ±0.1 .64 .40
Abbreviations: DLS, double-leg squat; FAI,femoroacetabular impingement; SLS, single-leg squat.
*Values are mean ± SD Newton meters per kilogram. Positive moments representflexion, adduction, and internal rotation. Negative moments represent exten­
sion, abduction, and external rotation.
1Statistically significant interaction o f group by task.

914 I DECEMBER 20 19 | VOLUME 4 9 | NUMBER 12 | JOURNAL OF ORTHOPAEDIC & SPORTS PHYSICAL THERAPY
act eccentrically to control hip joint ad­
duction as the CM descends (A PPEN DIX
FIGURE 2 ). In the sagittal plane, during
the descent phase of both the double-leg
and single-leg squat tasks, the hip exten­
sor muscles act eccentrically (APPEN DIX
FIGURES 3 and 4 ) . Therefore, slowing the
movement of the CM and lengthening
the duration of the squat cycle could re­
sult in lower net internal joint moments,
allowing the movement of the CM to be
controlled with less force at the hip.
Limitations
We cannot be certain that participants
without hip pain did not have cam and/
or pincer morphology because we did not
image their hips." However, the absence
of clinical signs and symptoms, such as
hip pain, reduced range of motion, and a
positive impingement test, rules out FAI
syndrome. The groups were matched
for height and weight but not for age.
Age could influence squat velocity. How­
ever, the average age of both groups was
between 20 and 30 years, and squat
mechanics are unlikely to be tangibly
affected by this difference. We did not
account for sex differences in the sample-
size calculation.13
Inclusion in our study required a posi­
tive response to an intra-articular injec­
tion and positive magnetic resonance
imaging and radiographic evidence of
FAI syndrome to ensure that hip symp­
toms had an intra-articular origin. Al­
though the heterogeneity of the sample
does represent a limitation, we feel that
Squat P erformance Variables D uring the D ouble -L eg and S ingle -L eg Squat
Tasks in P eople W ith FAI Syndrome and P eople W ithout H ip Pain
FAI Syndrome*
DLS
CM depth, m 0.46 + 0.11
CM descent velocity, m/b -0.28 + 0.10
CM ascent velocity, m/b 0.37 ±0.13
Squat cycle duration, s 3.13 ±0.86
Abbreviations: CM, center o f mass; DLS, double-leg squat; FAI,femoroacetabular impingement; SLS, single-leg squat
*Values are mean ± SD unless otherwise indicated.
‘Main effect o f group.
JO U R N A L OF O R TH O PA E D IC
the stringent inclusion criteria strength­
en the design and internal validity of the
study. Not controlling the trunk position
might influence hip joint internal mo­
ments, and the biomechanical results
could change if trunk position were con­
trolled. However, controlling the trunk
position may be difficult across tasks,
because this may require participants to
adopt an unnatural movement strategy.
Controlling trunk position may limit the
generalizability of the results for clini­
cal evaluation, which often involves as­
sessing patients who use a self-selected
movement strategy. Finally, extracting
peak kinematics and kinetics to repre­
sent a maximum angle or moment in a
particular direction for each task may
not have corresponded to the position of
maximum flexion combined with adduc­
tion and internal rotation.
CONCLUSION
S IN G L E -L E G SQUAT TASK E X A G G ER -
A
ated biomechanical differences at
the hip between people with FAI
syndrome and people without hip pain
when compared to a double-leg squat
task. People with FAI syndrome per­
formed squats more slowly than people
without hip pain. ®
■ KEY POINTS
FINDINGS:Differences in hip joint kine­
matics and kinetics between people with
femoroacetabular impingement syn­
drome and people without hip pain are
No Hip Pain*
SLS DLS SLS
0.25 ±0.08 0.47 ±0.13 0.32 ±0.07
-0.17 ±0.06 -0.39 ±0.17 -0.26 ±0.07
0.24 ±0.07 0.47 ±0.16 0.35 ±0.06
2.57 ±0.77 2.36 ±0.63 2.25 ±0.74
& SPO RTS PH YSICA L TH ERA PY | VO LU M E 4 9
exaggerated during a single-leg squat
when compared to a double-leg squat.
IMPLICATIONS: Clinicians might consider
using a single-leg squat task during move­
ment assessment of people with femoro­
acetabular impingement syndrome.
CAUTION: It is possible that the biome­
chanical alterations in squat perfor­
mance also depend on a person’s sex.
ACKNOWLEDGMENTS: The authors would like
to thank D r John Heinrichjbr his assistance
with patient referralsfor this study. We would
also like to thank Michael Kiely, Alexander
Morgan, and Matthew Giordanellifor their
assistance with data collection.
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